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Officeholder, Candidate, Tv.or printin ink. COVER PAGE- LONG FORM <br /> (Government Code Sections 84200-84216.5)Campaignand Controlled Committeestatement -- LongForm I State'mint ¢°vers PeEi°d iifrom M" ...... '~' '~-'~ '- *~ ~'--'; :'~'i,' ~ ~ ~; ,~/'~ Date Stampi <br /> SEE INSTRUCTIONS ON REVERSE <br /> Check one of the following boxes to indkate the type of statement being filed: O, te of election if ,ppliC~ble:l U ~ t ~ ! -- -- <br /> g] Pr., ,on St.t.m.nt D,. ,...)! /J ...... For U. On, <br /> Supplemental PrHleCtion Statement (Attach a completed Form 495 tothis statement.)I / CJ~ ~?!; i:,:~ <br /> Special Odd-Year Campaign Report - ~ ~!~ ~ 7. ~ <br /> Semi-~nnuel Statement <br /> Termination Statement (Attach I completed Form 41S to this statement.) <br /> tatement: <br /> Im ~is Statement corem/trees not included in this consolidated s~etement that are controlled by you and any <br /> NAME OF OFFICE#OLOE.q OR CANI~ATE . , ~-- ~ comntittees of which you have knowledge thet ere primedly formed to receive cmtHbuticms <br /> <br /> OFFIC~'SOUGHT OF~ HELD~ MIC[U(~ LbCATION AND IMSTklCT Ir#jMl~# I~ APq(dCAl~) <br /> <br /> RESIDENTIAL oa B~eNFE SS AGOI~SS ~(NO. AN{) STRIET) NAME O~ TRF. AMJ~R CONTREX. LED COMMITI'EEI <br /> <br /> COMMITTEE NAME -" ! ~ ~ ! I'D'NUMIEll CITY gATE ZlPCOOF AIIL4COOEA)AYTIMEPHON~ <br /> <br /> OTy..~_ - u ;~ STATE YTIMEFtK~I~ NIddEOFT~ASU~ER COflTROLLEDCOMMITTEEt <br /> <br /> I,. <br />· -~ NAME'OF TREASURER ! ' "' ' COMMITrEE ADOIIESS MO. AND STREET) <br /> ,~mAm~S$~TMAS~Z~' ~. ~ - I.O. AN~STP~Lm C~ STATE <br /> <br /> III Vtrifi~atio. <br /> '~ I have used all reasonable diligence in preparing this statement. I have reviewed the statement and to the best of my knowledge the information contained herein and in the attached schedules is <br /> true end complete. I certify under penalty of perjury under the laws of the State of California that the foregoing is true end correct. <br /> <br /> ~ Executed on At By <br /> DATE CITY AND STATE SIGNATURE or TREASURER <br /> <br /> An officeholder or candidate who controls I committee must also verify the campaign statement. I have used all reasonable diligence and to the best of my ~nowledge the treasurer has used all <br /> reasonable diligence in preparing this statement. I have reviewed the statement and to the hast of my knowledge the information contained herein and in the attached Khedules is true and <br /> complete I certify under penalty of perjury under the laws of the State of California that the foregoing is true end correct. . ~ <br /> <br /> ~/ ~" ~'/ ~: ~ / '"' A D <br /> <br /> Executed on At By '" ./~' . <br /> i DATE ¢,¥ AND STATE SK;NATURE OF C~ND~DA!~./Q~C'EfloLDER <br /> Executed on At By <br /> DATE CnY AND STATE SIGNAlURE OF CANDIDATE/OFFICEHOLDER <br /> <br /> FOP, INFOAMATION I~QUII~D 10 RE PROVIDED TO YOU PUP`SUANT TO THE INFOP,MATION PKACTICES ACT OF 1~77, SEE INF~)AMATION MAi~¥AL IDN CAMPAIGH DISCLOSURE PP`OVISH;)NS OF THE POLITICAL AEFOAM ACT <br /> <br /> <br />